implementing modified same-day discharge protocol

Funding Acknowledgements

Type of funding sources: None.

Introduction

To accomplish overcapacity and bed lacks same-day discharge post percutaneous coronary intervention (PCI) has appeared as a key to improve resource consumption. Also, to focus on evaluating the length of hospital stay (LOS) post PCI’s patients and how to decrease the LOS or same day discharge .

Aim

A quality improvement project that aimed for implementing new modified Same Day Discharge (SDD) protocol post- Percutaneous Coronary Intervention (PCI) in purpose to decreasing the patient LOS, resources utilization, improving patient satisfactions, manage overcrowded, bed shortages, and bed-flow efficiency.

Methods

After modifying the protocol to fit with the new cardiac care setting.

Orientation for staff nurses about SDD protocol.

Statistical results compared to determine the impact of the new modified SDD protocol regarding the LOS. (Figure B)

Patients who fit the criteria will be discharge on the same day post PCI. (Figure C)

Results & Data Analysis

During Sep. 2020, the total patients were 196 (PCI 64 Patients ) compared to 165 (PCI 26 Patients) on Sep. 2021.

PCI patients who met the SDD criteria and did not discharge were 48% on Sep. 2020 compared to 19% on Sep. 2021.

As showing on the data there is significant impact of the SDD modified protocol, there are 29% increased on the patient discharge.

Recommendation

Continuous using of these criteria.

Link the patient LOS to the data to assess how the SDD Impact and to support the result.

Conclusion

SDD protocol for post PCI patient in carefully selected patients that improve the patient discharge process.

Mesh versus suture repair of primary inguinal hernia in Ghana

Background

Most patients in Ghana undergo suture repair for primary inguinal hernia. Although there is strong evidence from high‐income country settings to indicate superiority of mesh repair for inguinal hernia, the evidence to support the safety and effectiveness of mesh repair in the Ghanaian setting is limited. This study aimed to compare hernia recurrence rates following suture versus mesh repair in Ghana.

Methods

Men aged 18 years or over presenting with symptomatic, reducible inguinal hernias were included. Over the first 6 months all consecutive patients were enrolled prospectively and underwent a standardized suture repair; an equal number of patients were subsequently enrolled to undergo mesh repair. The primary outcome was hernia recurrence within 3 years of the index operation. Multivariable analysis was adjusted for age and right or left side. Adjusted odds ratios (ORs) with 95 per cent confidence intervals are reported.

Results

A total of 116 sutured and 116 mesh inguinal hernia repairs were performed. Three years after surgery, follow‐up data were available for 206 of the 232 patients (88·8 per cent). Recurrence occurred significantly more frequently in the suture repair group (23 of 103, 22·3 per cent) than in the mesh group (7 of 103, 6·8 per cent) (P = 0·002). In multivariable analysis, suture repair was independently associated with an increased risk of recurrence (OR 4·51, 95 per cent c.i. 1·76 to 11·52; P = 0·002).

Conclusion

In Ghana, mesh inguinal hernia repair was associated with reduced 3‐year recurrence compared with sutured repair. Controlled dissemination across Ghana should now be assessed.

Search for OIE-listed ruminant mycoplasma diseases in Afghanistan

BACKGROUND

Little is known about the occurrence of important diseases of ruminants in Afghanistan because of the conflict affecting the country over the last 40 years. To address this discrepancy, ruminant herds in Afghanistan were screened for OIE-listed mycoplasma diseases, contagious bovine (CBPP) and caprine pleuropneumonias (CCPP).

RESULTS

Of the 825 samples from 24 provinces tested for serological evidence of CBPP caused by Mycoplasma mycoides subsp.mycoides, 20 (3.4%) had ELISA values greater than the positive threshold of 50% though all were less than 55%. Repeat testing of these suspect sera gave values below 50. A smaller number of sera (330) from cattle in nine provinces were also tested by the rapid latex agglutination test (LAT) for CBPP, 10 of which were considered suspect. However, no positive bands were seen when immunoblotting was carried out on all sera that gave suspect results. Serological evidence of Mycoplasma bovis was detected in half of 28 herds in eight provinces. The cause of CCPP, M. capricolum subsp. capripneumoniae was not detected in any of the 107 nasal swabs and lung tissue collected from goats in seven provinces though sample handling and storage were not optimal. However, strong serological evidence was detected in goat herds in several villages near Kabul some of which were over 50% seropositive by LAT and ELISAs for CCPP; immunoblotting confirmed positive results on a selection of these sera.

CONCLUSIONS

The data presented here provide a first assessment of the occurrence of the two OIE listed mycoplasma diseases in Afghanistan. From the results of the testing bovine sera from the majority of provinces there is no evidence of the presence of CBPP in Afghanistan. However the samples tested represented only 0.03% of the cattle population so a larger survey is required to confirm these findings. Serological, but not bacterial, evidence was produced during this investigation to show that CCPP is highly likely to be present in parts of Afghanistan.

Selective organ preservation with neo-adjuvant chemotherapy for the treatment of muscle invasive transitional cell carcinoma of the bladder

BACKGROUND

Radiotherapy for muscle invasive bladder cancer (MIBC) aims to offer organ preservation without oncological compromise. Neo-adjuvant chemotherapy provides survival advantage; response may guide patient selection for bladder preservation and identify those most likely to have favourable result with radiotherapy.

METHODS

Ninety-four successive patients with T2-T4aN0M0 bladder cancer treated between January 2000 and June 2011 were analysed at the Royal Marsden Hospital. Patients received platinum-based chemotherapy following transurethral resection of bladder tumour; repeat cystoscopy (± biopsy) was performed to guide subsequent management. Responders were treated with radiotherapy. Poor responders were recommended radical cystectomy. Progression-free survival (PFS), disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meier method; univariate and multivariate analyses were performed using the Cox proportional hazard regression model.

RESULTS

Response assessment was performed in 89 patients. Seventy-eight (88%) demonstrated response; 53 (60%) achieved complete response (CR); 74 responders had radiotherapy; 4 opted for cystectomy. Eleven (12%) demonstrated poor response, 10 received cystectomy. Median survival for CR was 90 months (95% CI 64.7, 115.9) compared with 16 months (95% CI 5.4, 27.4; P < 0.001) poor responders. On multivariate analysis, only response was associated with significantly improved PFS, OS and DSS. After a median follow-up of 39 months (range 4-127 months), 14 patients (16%) required salvage cystectomy (8 for non-muscle invasive disease, 5 for invasive recurrence, 1 for radiotherapy related toxicity). In all, 82% had an intact bladder at last follow-up after radiotherapy; 67% had an intact bladder at last follow-up or death. Our study is limited by its retrospective nature.

CONCLUSIONS

Response to neo-adjuvant chemotherapy is a favourable prognostic indicator and can be used to select patients for radiotherapy allowing bladder preservation in >80% of the selected patients.

Effects of metsulphuron-methyl on amylase, invertase and xylanase activities in two soil types

Effects of metsulphuron-methyl on the activities of amylase, invertase and xylanase in loamy sand and clay were evaluated for up to 28 days under laboratory conditions. Metsulphuron-methyl at 1.0 microg/g caused a significant reduction in amylase, invertase and xylanase activities for the entire period of study, especially at 28 days incubation in both soils. The lowest activities of the three enzymes were observed in the presence of 5.0 microg/g at 28 days incubation.

Anti-fasciola IgG isotypes among patients with fascioliasis before and after treatment

Stool examination using modified Kato thick smear method was performed to detect Fasciola eggs and other parasites. Abdominal pain was the major presenting symptom (83.3%) followed by pallor (71.6%) and fever (16.7%). Anaemia and hepatomegaly were recorded in 70% of patients compared to 25% with splenomegaly. Abdominal ultrasonography revealed hepatomegaly and common bile duct dilatation in 70% of patients. Moreover, 6 cases showed Olympic game rings which is diagnostic. All of patients had positive IgG4 levels, 58 cases were found positive for specific total IgG and IgG1, whereas, only 36 cases had positive IgG2 levels (60%). All negative control group showed no cross reactions. On the other hand, ELISA detecting IgG4 showed the highest specificity (95%), followed by IgG2 (85%) and the least specific test was obtained with detection of IgG (70%) and IgG1 (65%). One week after treatment, 90% of patients were completely cured. One and 3 months after treatment, the cure rate was 83.3%. In completely cured patients, none of anti-Fasciola isotypes was significantly changed.

In vitro analysis of AcrySof intraocular lens glistenings in AcryPak and Wagon Wheel packaging

PURPOSE

To compare the formation of "glistenings" in acrylic intraocular lenses (IOLs) packaged in Wagon Wheel and AcryPak packaging systems.

SETTING

John Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

METHODS

Acrylic IOLs in Wagon Wheel (WW) and AcryPak (AP) packaging were analyzed in vitro. The lenses were placed in a test chamber with a controlled temperature and evaluated every 48 hours for 336 hours. The presence of glistenings within the lens optic was assessed using slitlamp evaluation and a quantitative microscopic evaluation with an image analysis system.

RESULTS

When maintained at a constant temperature, the WW-packaged IOLs showed no glistening formation and the AP-packaged IOLs, significant glistening formation. Glistenings were noted in the WW-packaged IOLs only under fluctuating temperature conditions. Quantitative image analysis confirmed the presence of glistenings only in AP-packaged IOLs maintained at a constant temperature.

CONCLUSION

The glistenings in AcrySof IOLs were temperature dependent and confined to IOLs packaged in AcryPak folders and maintained at constant (body) temperatures. These findings are believed to be consistent with fluid formation within the acrylic optic, somehow related to the AcryPak packaging system.

Scanning electron microscopic characteristics of small-incision intraocular lenses

PURPOSE

To evaluate the surface characteristics of commonly used, small-incision, intraocular lenses (IOLs).

METHODS

Representative samples of five groups of foldable IOLs (4 silicone and 1 acrylic) underwent surface and edge-finish examination using a slit lamp. The IOLs were folded using a folding block and forceps. All the IOLs then were examined using a scanning electron microscope. A one-piece polymethylmethacrylate IOL was used for comparing surface-finish characteristics. The IOLs were examined for optic surface quality, edge finish, haptic, haptic/optic junction, and possible post-folding modifications.

RESULTS

Slit-lamp evaluation of the surface quality of all of the silicone lenses demonstrated a smooth finish of the optic surface, edge, and haptics. Scanning electron microscopic analysis of the IOLs demonstrated adequately finished haptics or footplates and optics. Excess molding flash was seen on the edges of the some of the silicone IOLs, and no molding flash was observed on others. The acrylic IOL had a somewhat sharper optic edge. Irregular finish of the haptic/optic junctions of some of the IOLs (both silicone and acrylic) was noted.

CONCLUSIONS

Currently available foldable IOLs have demonstrated adequate lens finish. However, irregularities of the haptic/optic junctions and molding flash are present on most IOLs evaluated, indicating room for improvement in the finish of foldable IOLs. Phacoemulsification with capsular bag IOL placement may decrease the clinical significance of these relatively subtle lens finish irregularities.

Visual significance of glistenings seen in the AcrySof intraocular lens

PURPOSE

To investigate the visual significance of "glistenings" in acrylic intraocular lenses (IOLS).

SETTING

John Moran Eye Center, University of Utah, Salt Lake City.

METHODS

Seventeen patients who had phacoemulsification with implantation of the AcrySof acrylic IOL were evaluated by slitlamp examination and visual acuity, contrast sensitivity, and glare testing. Ten patients had a silicone posterior chamber IOL in the opposite eye and had testing with similar visual parameters for comparison. Glistenings noted in the acrylic IOLs were graded at the slitlamp. Laboratory analysis of five acrylic IOLs was also done to reproduce the glistenings noted clinically.

RESULTS

All 17 patients with the acrylic IOLs had some lenticular glistenings, ranging from trace to 2+. Statistical analysis of visual acuity, contrast sensitivity, and glare testing revealed a statistically significant difference between the acrylic and the silicone IOLs only in contrast sensitivity. Laboratory analysis of the acrylic IOLs showed similar glistenings from 48 to 72 hours after they were placed in balanced salt solution.

CONCLUSIONS

A patients who received AcrySof IOLs that came in the AcryPak had some degree of glistenings. There was also a significant decrease in contrast sensitivity compared with that of fellow eyes with silicone IOLs. The glistenings are likely caused by water vacuoles that form within the lens after hydration within the eyes. Further studies are necessary to assess the exact cause of these glistenings.

Capsular bag distension with an acrylic intraocular lens

PURPOSE

To describe the postoperative capsular bag distension that occurs with in-the-bag implantation of the soft acrylic (AcrySof) intraocular lens (IOL).

SETTING

Jules Stein Eye Institute, University of California, Los Angeles.

METHODS

Nine eyes in nine patients had uncomplicated continuous curvilinear capsulorhexis, phacoemulsification, and in-the-bag implantation of the AcrySof lens. Comprehensive ophthalmic examinations were performed 1 day and 1 and 6 weeks postoperatively. Patients had neodymium:YAG laser posterior capsulotomy; refractions were done before and after the capsulotomy.

RESULTS

Comprehensive ophthalmic examination revealed variable degrees of anterior chamber shallowing, anterior displacement of the IOL within the bag, and distension of the posterior capsule away from the IOL. Unexpected postoperative myopic correction was seen in all patients. Postcapsulotomy mean spherical equivalent refractive shift was +3.6 diopters (D) with a shift of at least +4.0 D in four of nine eyes.

CONCLUSIONS

Capsular bag distension is a previously described postoperative complication that we observed in association with the AcrySof IOL.

Comparison of two plate-haptic intraocular lenses in a rabbit model

PURPOSE

To compare the presence of fibrosis through footplate positioning holes in two different silicone intraocular lenses (IOLs) following phacoemulsification with IOL implantation.

SETTING

Moran Eye Center, University of Utah, Salt Lake City.

METHODS

Twelve New Zealand white rabbits had phacoemulsification with placement of a control silicone IOL in one eye and a study IOL with a larger positioning hole in the opposite eye. The amount of force required to remove the IOLs from the capsular bag was analyzed at 3 and 6 weeks postoperatively.

RESULTS

The force necessary to remove the study lens with the larger positioning holes was statistically significantly greater at both 3 and 6 weeks than that necessary to remove the control lenses. Capsular fibrosis with proliferative lens cortical material through the larger positioning holes was also documented grossly using the Miyake technique.

CONCLUSION

The larger footplate positioning holes in the study silicone IOL significantly increased capsular bag fixation in the rabbit model following phacoemulsification and IOL implantation.

Resistance of Pseudomonas pseudomallei to normal human serum bactericidal action

The effect of human normal serum (HNS) on Pseudomonas pseudomallei was determined. It is apparent from our data that the organism is resistant to the normal serum bactericidal mechanism. Ancillary experiments to confirm this serum-resistant property of P. pseudomallei were done by examining the effects of growth phase conditions of the bacteria (i.e., logarithmic and stationary phases) and different buffered systems used as diluent in our bactericidal assay. Results obtained showed similar degree of resistance to serum bactericidal killing by 5 strains of the organisms tested. The possible survival advantage of serum-resistance property to P. pseudomallei as bacterial pathogens known to invade the blood stream is discussed.

A competitive immunosorbent assay for detection of Pseudomonas pseudomallei exotoxin

The development of monoclonal antibody and enzyme-linked immunosorbent assay (ELISA) techniques has made possible the detection of specific antigens at extremely low concentrations. Diagnosis of recalcitrant diseases such as melioidosis depends upon either early isolation and identification of the causative organism or the identification of a specific marker antigen, Pseudomonas pseudomallei exotoxin, in serum; the latter is better because it allows more rapid and simple diagnosis. A method of detecting exotoxin concentrations of greater than 16 ng/ml by an ELISA based on a monoclonal antitoxin is here described; it is significantly more sensitive than the mouse lethality test (lower threshold 30 micrograms/ml) currently in use and an in-vitro cytotoxicity test (lower threshold 10 micrograms/ml) that we have developed and describe here.